Provider Demographics
NPI:1104245562
Name:VIDALIS, BENJAMIN (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:VIDALIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BENJAMIN
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:MSC 10 5615
Mailing Address - Street 2:UNIVERSITY OF NEW MEXICO
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-272-3160
Mailing Address - Fax:505-272-9427
Practice Address - Street 1:465 SAINT MICHAELS DR STE 107
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7690
Practice Address - Country:US
Practice Address - Phone:505-988-3233
Practice Address - Fax:505-988-3562
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM390200000X
NMMD2021-0303207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program